| NPI | 1518457118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 104820) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10812349-9922) |
| Enumeration Date | 2018-05-18 |
| Last Update Date | 2022-06-20 |