NPI | 1619049012 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 56163) |
Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 21231) |
Enumeration Date | 2006-11-14 |
Last Update Date | 2011-03-09 |