| NPI | 1356790976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 37166) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS100226) |
| Enumeration Date | 2016-06-04 |
| Last Update Date | 2021-07-01 |