| NPI | 1184265563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 13316) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 104078) |
| Enumeration Date | 2019-10-07 |
| Last Update Date | 2023-06-12 |