| NPI | 1952656621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 63385) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL11574) |
| Enumeration Date | 2012-07-19 |
| Last Update Date | 2016-06-01 |