| NPI | 1639368434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 41302) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD5059) |
| Enumeration Date | 2007-10-17 |
| Last Update Date | 2022-06-07 |