| NPI | 1558385617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 26028) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 48751) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2021-01-11 |