| NPI | 1659529642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 102739) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412140) |
| 122300000X Dentist (Licence: WA DE60538445) | |
| Enumeration Date | 2008-09-03 |
| Last Update Date | 2018-07-10 |