| NPI | 1659449791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 58231) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 0515061) |
| Enumeration Date | 2006-11-30 |
| Last Update Date | 2011-01-31 |