| NPI | 1104512011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30736) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 108348) |
| Enumeration Date | 2023-04-13 |
| Last Update Date | 2026-06-22 |