| NPI | 1245701465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D4311) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 20323) |
| Enumeration Date | 2018-12-16 |
| Last Update Date | 2018-12-16 |