| NPI | 1336688704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO DEN.00203469) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS102765) |
| Enumeration Date | 2017-02-18 |
| Last Update Date | 2022-05-16 |