| NPI | 1508045394 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 54196) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 54196) |
| Enumeration Date | 2007-10-29 |
| Last Update Date | 2024-12-02 |