| NPI | 1063869709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: GA 123227) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100190) |
| 1223P0300X Dentist, Periodontics (Licence: FL 24533) | |
| Enumeration Date | 2016-05-23 |
| Last Update Date | 2023-08-21 |