| NPI | 1851695639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 36406) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: CA 36406) |
| Enumeration Date | 2011-01-07 |
| Last Update Date | 2011-02-16 |