| NPI | 1518379122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 63633) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 9764) |
| Enumeration Date | 2014-05-30 |
| Last Update Date | 2014-08-20 |