| NPI | 1831211564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 60457) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ 4536) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2017-02-10 |