| NPI | 1770609737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 64135) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 19027) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2017-04-06 |