| NPI | 1063870483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859541) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100962) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-01-29 |
| Last Update Date | 2023-06-16 |