| NPI | 1730440553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 65010) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856173) |
| 122300000X Dentist (Licence: FL DN19701) | |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2021-09-16 |