| NPI | 1043695513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12810) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA dds101899) |
| 122300000X Dentist (Licence: MA DN1856859) | |
| Enumeration Date | 2015-07-27 |
| Last Update Date | 2023-01-13 |