| NPI | 1801026273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 58476) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 25516) |
| Enumeration Date | 2009-07-20 |
| Last Update Date | 2011-05-03 |