| NPI | 1992953236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27485) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 57125) |
| Enumeration Date | 2008-08-28 |
| Last Update Date | 2021-06-28 |