| NPI | 1013264357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 103604) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA DL11672) |
| Enumeration Date | 2012-08-06 |
| Last Update Date | 2022-11-29 |