| NPI | 1184119604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 104769) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00203658) |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2026-07-24 |