| NPI | 1407838915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 37300) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D3145) |
| 122300000X Dentist (Licence: CO 7786) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2008-09-10 |