| NPI | 1760852917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA DDS65183) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00202682) |
| 1223P0300X Dentist, Periodontics (Licence: UT 13661508-9926) | |
| Enumeration Date | 2015-09-30 |
| Last Update Date | 2024-02-19 |