| NPI | 1366012965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 108357) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1002671-15) |
| Enumeration Date | 2021-06-28 |
| Last Update Date | 2023-03-21 |