| NPI | 1710103486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: CA 53072) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 53072) |
| Enumeration Date | 2007-04-18 |
| Last Update Date | 2011-11-15 |