| NPI | 1619989670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00202445) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 53991) |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2022-02-08 |