| NPI | 1063882504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 100077) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60587475) |
| Enumeration Date | 2015-09-27 |
| Last Update Date | 2021-09-27 |