| NPI | 1629180617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 33512) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 33512) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2014-08-01 |