| NPI | 1497727754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 111304) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 13821) |
| 1223G0001X Dentist, General Practice (Licence: WV 4237) | |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2025-04-30 |