| NPI | 1639650245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 104508) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 34440) |
| Enumeration Date | 2018-08-22 |
| Last Update Date | 2022-02-23 |