| NPI | 1740514645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 3629539922) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 105921) |
| Enumeration Date | 2009-09-24 |
| Last Update Date | 2021-03-05 |