| NPI | 1164115713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 110503) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO DEN.00205637) |
| Enumeration Date | 2023-05-31 |
| Last Update Date | 2024-08-08 |