| NPI | 1790750610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 23573) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 52866) |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2011-11-09 |