| NPI | 1730312836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 58487) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 27221) |
| Enumeration Date | 2009-08-24 |
| Last Update Date | 2013-06-12 |