| NPI | 1639368582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 109231) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417561) |
| 122300000X Dentist (Licence: OR D8993) | |
| Enumeration Date | 2007-10-16 |
| Last Update Date | 2024-10-01 |