| NPI | 1730578428 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS100055) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00202426) |
| 122300000X Dentist (Licence: NV 6599) | |
| Enumeration Date | 2015-01-18 |
| Last Update Date | 2018-03-17 |