| NPI | 1902928476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 44179) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS029217L) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2007-07-08 |