| NPI | 1518141456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 55571) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NC 9871) |
| Enumeration Date | 2007-12-27 |
| Last Update Date | 2014-08-29 |