| NPI | 1497036172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 60524) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 27525) |
| Enumeration Date | 2011-09-08 |
| Last Update Date | 2013-10-09 |