| NPI | 1194218776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 102441) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 36370) |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2021-07-21 |