| NPI | 1902960693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 38104) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA B 38104) |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2014-10-03 |