| NPI | 1275161135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 106964) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 106964) | |
| Enumeration Date | 2020-03-27 |
| Last Update Date | 2022-07-13 |