| NPI | 1528612041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 104213) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 104213) |
| Enumeration Date | 2019-08-01 |
| Last Update Date | 2019-08-01 |