| NPI | 1255787479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NV S4-131) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100189) |
| Enumeration Date | 2016-05-06 |
| Last Update Date | 2022-11-22 |