| NPI | 1407146228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 61495) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: CA 61495) | |
| Enumeration Date | 2011-04-13 |
| Last Update Date | 2017-04-10 |