| NPI | 1609138528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 63146) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D9716) |
| 122300000X Dentist (Licence: NV 6274) | |
| Enumeration Date | 2012-06-15 |
| Last Update Date | 2014-03-11 |