| NPI | 1235785361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 105976) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 100217915) |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2021-05-05 |