| NPI | 1457701294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS102423) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040949) |
| Enumeration Date | 2016-06-13 |
| Last Update Date | 2021-10-02 |