| NPI | 1689982555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 59766) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 59766) |
| 1223P0300X Dentist Periodontics (Licence: NY 057811-1) | |
| Enumeration Date | 2010-09-14 |
| Last Update Date | 2021-12-03 |