| NPI | 1861702557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA DDS101101) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS101101) |
| Enumeration Date | 2010-10-14 |
| Last Update Date | 2026-07-07 |