| NPI | 1255031464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 111393) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 111393) |
| Enumeration Date | 2023-03-07 |
| Last Update Date | 2025-07-04 |