| NPI | 1558671065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 59695) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 59695) |
| Enumeration Date | 2010-10-18 |
| Last Update Date | 2012-07-02 |