| NPI | 1871955336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA DDS100287) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NM DD4470) |
| Enumeration Date | 2016-03-24 |
| Last Update Date | 2017-02-09 |