| NPI | 1902034903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 8462) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 58369) |
| 122300000X Dentist (Licence: UT 7480754-9922) | |
| Enumeration Date | 2009-06-29 |
| Last Update Date | 2016-01-08 |