| NPI | 1578880985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25382) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 59240) |
| Enumeration Date | 2010-04-24 |
| Last Update Date | 2016-05-19 |