| NPI | 1619224300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 62114) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 28231) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2013-04-30 |