| NPI | 1538416441 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS10299) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 8352806-9922) |
| Enumeration Date | 2012-08-09 |
| Last Update Date | 2018-04-11 |