| NPI | 1457669046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 58366) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D7804) |
| Enumeration Date | 2010-09-17 |
| Last Update Date | 2014-06-05 |