| NPI | 1720095631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 9231171-9921) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 26994) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2015-12-08 |