| NPI | 1861805954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 104243) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: PA DS041256) |
| Enumeration Date | 2014-06-05 |
| Last Update Date | 2020-03-24 |