| NPI | 1881742526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA 59926) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA 21324) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2010-12-13 |