| NPI | 1770615734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 38948) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 20422) |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2007-07-08 |