| NPI | 1710355151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33288) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 64666) |
| 1223G0001X Dentist, General Practice (Licence: CA 64666) | |
| Enumeration Date | 2015-09-02 |
| Last Update Date | 2017-09-01 |