| NPI | 1538790944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS106906) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO DEN.00204261) |
| Enumeration Date | 2020-02-04 |
| Last Update Date | 2021-10-12 |