| NPI | 1134854979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 110069) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 38715) |
| Enumeration Date | 2022-07-17 |
| Last Update Date | 2025-02-21 |