| NPI | 1083247381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 104379) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901022494) |
| Enumeration Date | 2020-02-15 |
| Last Update Date | 2020-02-15 |