| NPI | 1114561198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D15004) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA DDS104406) |
| Enumeration Date | 2019-11-01 |
| Last Update Date | 2023-09-19 |