| NPI | 1992103642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 63279) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS040224) |
| Enumeration Date | 2014-12-11 |
| Last Update Date | 2015-10-01 |