| NPI | 1881986859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D9699) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 6662-15) |
| Enumeration Date | 2011-05-10 |
| Last Update Date | 2014-09-30 |