| NPI | 1154798320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 103772) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-4678) |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2022-01-04 |