| NPI | 1104075175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 30354) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 30354) |
| 171100000X Acupuncturist (Licence: CA AC1426) | |
| Enumeration Date | 2008-09-15 |
| Last Update Date | 2024-01-04 |