| NPI | 1639159858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 61754) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: UT 375678) |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2013-10-16 |