| NPI | 1679794440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 50754) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS038199) |
| 1223G0001X Dentist, General Practice (Licence: DE G1-0001311) | |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2012-08-19 |