| NPI | 1477639375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 56454) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS035993) |
| 1223G0001X Dentist, General Practice (Licence: WA DE00010877) | |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2007-10-31 |