| NPI | 1558148965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123545) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 109267) |
| Enumeration Date | 2023-09-11 |
| Last Update Date | 2024-08-01 |