| NPI | 1558819706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 102146) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 32214) |
| Enumeration Date | 2016-09-16 |
| Last Update Date | 2018-03-17 |