| NPI | 1558684472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: UT 7596413) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 58433) |
| Enumeration Date | 2010-03-05 |
| Last Update Date | 2010-06-09 |