| NPI | 1396964086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 38532) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 38532) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2020-10-13 |