| NPI | 1811276413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 27617) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 27617) |
| Enumeration Date | 2011-08-12 |
| Last Update Date | 2011-08-12 |