| NPI | 1790839629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 57041) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MN D12354) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2011-08-11 |