| NPI | 1528705993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 108822) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MN D14747) |
| Enumeration Date | 2022-05-17 |
| Last Update Date | 2024-05-24 |