| NPI | 1164195475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 106754) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 106754) |
| Enumeration Date | 2021-08-01 |
| Last Update Date | 2025-05-21 |