| NPI | 1376755942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 59276) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019205) |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2022-02-10 |