| NPI | 1730253253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 56924) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 5050) |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2012-02-28 |