| NPI | 1811160880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 57680) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 27346) |
| Enumeration Date | 2008-04-10 |
| Last Update Date | 2019-09-19 |