| NPI | 1184982068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 100205) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA 09281) |
| Enumeration Date | 2012-04-27 |
| Last Update Date | 2018-04-30 |