| NPI | 1902217490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 110570) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9415) |
| 1223P0300X Dentist, Periodontics (Licence: VA 0401415627) | |
| Enumeration Date | 2014-05-19 |
| Last Update Date | 2024-10-31 |