| NPI | 1154519296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14862) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 56420) |
| Enumeration Date | 2007-10-12 |
| Last Update Date | 2026-06-16 |