| NPI | 1104252154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA DDS112333) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 10809) |
| 1223G0001X Dentist, General Practice (Licence: NC 10809) | |
| Enumeration Date | 2013-09-23 |
| Last Update Date | 2025-10-30 |