| NPI | 1184090201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 105682) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13543) |
| 122300000X Dentist (Licence: NY 060300) | |
| Enumeration Date | 2015-08-12 |
| Last Update Date | 2021-05-07 |