| NPI | 1710386974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 102047) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 30394) |
| Enumeration Date | 2014-08-13 |
| Last Update Date | 2022-10-18 |