| NPI | 1083157549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 101058) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 139962939926) |
| 122300000X Dentist (Licence: AZ 10557) | |
| Enumeration Date | 2016-11-30 |
| Last Update Date | 2025-01-22 |