| NPI | 1528347291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 62190) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50 055721) |
| Enumeration Date | 2011-08-11 |
| Last Update Date | 2013-03-12 |