| NPI | 1104434448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 106028) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14441) |
| Enumeration Date | 2020-07-22 |
| Last Update Date | 2021-02-25 |