| NPI | 1467604454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D6465) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 38733) |
| Enumeration Date | 2008-10-21 |
| Last Update Date | 2012-06-15 |