| NPI | 1770626921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA OMS031) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA A71195) |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2007-07-08 |