| NPI | 1083255111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 104439) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: CA 104439) |
| Enumeration Date | 2019-09-30 |
| Last Update Date | 2019-10-28 |