| NPI | 1104373612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS106114) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60670424) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2023-10-12 |