| NPI | 1205218922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 103479) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: FL 22153) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-06-19 |
| Last Update Date | 2022-03-02 |