| NPI | 1275673618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 31336) |
| Additional Taxonomies | 122300000X Dentist (Licence: MT 2382) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2021-04-06 |