| NPI | 1962606301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 62113) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 19027352) |
| 122300000X Dentist (Licence: AZ D 7753) | |
| 122300000X Dentist (Licence: WI 6305-15) | |
| Enumeration Date | 2007-06-11 |
| Last Update Date | 2017-08-15 |