| NPI | 1417152430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 62908) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 14099) |
| 122300000X Dentist (Licence: VA 0401412328) | |
| Enumeration Date | 2007-06-19 |
| Last Update Date | 2014-01-21 |