| NPI | 1558790915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 32858) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 32858) |
| Enumeration Date | 2013-11-06 |
| Last Update Date | 2024-01-14 |