| NPI | 1558746388 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA DDS102295) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15927) |
| Enumeration Date | 2015-07-22 |
| Last Update Date | 2019-10-07 |