| NPI | 1770958068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 44730) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 44730) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 44730) | |
| Enumeration Date | 2015-12-11 |
| Last Update Date | 2015-12-11 |