| NPI | 1649565557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 60539) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401413249) |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2012-04-04 |