| NPI | 1700980703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 5616) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 20009) |
| Enumeration Date | 2006-09-11 |
| Last Update Date | 2015-04-02 |