| NPI | 1760461214 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA de60354477) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: CA 60692) |
| Enumeration Date | 2006-01-12 |
| Last Update Date | 2016-09-17 |