| NPI | 1497283915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 107608) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022269) |
| Enumeration Date | 2017-05-28 |
| Last Update Date | 2023-04-12 |