| NPI | 1104278837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 101672) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA DDS101672) |
| Enumeration Date | 2016-07-06 |
| Last Update Date | 2022-03-29 |