| NPI | 1740619212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 64460) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 29385) |
| Enumeration Date | 2013-11-05 |
| Last Update Date | 2021-03-11 |