| NPI | 1417178872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 42854) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV Temporary License) |
| Enumeration Date | 2007-05-02 |
| Last Update Date | 2007-07-08 |