| NPI | 1497817191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 57031) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 050824) |
| Enumeration Date | 2006-12-16 |
| Last Update Date | 2014-12-05 |