| NPI | 1205203304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 65023) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00203260) |
| Enumeration Date | 2015-08-25 |
| Last Update Date | 2022-07-21 |