| 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 |