| NPI | 1073968863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401410086) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 108472) |
| Enumeration Date | 2016-04-28 |
| Last Update Date | 2023-10-03 |