| NPI | 1518947704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 60626) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 5652896) |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2016-01-05 |