| NPI | 1467697011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 38837) |
| Additional Taxonomies | 122300000X Dentist (Licence: MT 2332) |
| 122300000X Dentist (Licence: WV 4037) | |
| 122300000X Dentist (Licence: MO 2013002262) | |
| Enumeration Date | 2008-12-11 |
| Last Update Date | 2015-04-13 |