| NPI | 1578971495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 63240) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 63240) |
| 1223G0001X Dentist, General Practice (Licence: TX 31545) | |
| 1223G0001X Dentist, General Practice (Licence: NM DD4193) | |
| Enumeration Date | 2014-07-23 |
| Last Update Date | 2022-01-24 |