| NPI | 1710269675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 64181) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AZ D008318) |
| Enumeration Date | 2011-09-15 |
| Last Update Date | 2017-04-10 |