| NPI | 1831211564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 60457) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 028841) |
| 1223G0001X Dentist, General Practice (Licence: AZ 4536) | |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2025-06-04 |