| NPI | 1508913021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CA A73900) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA OMS36) |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2023-02-13 |