| NPI | 1538353511 |
|---|---|
| Other Name | N/A N/A |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 54974) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AZ 5863) |
| Enumeration Date | 2007-08-31 |
| Last Update Date | 2008-05-19 |