| NPI | 1558775718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 63191) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 63191) |
| Enumeration Date | 2014-06-16 |
| Last Update Date | 2019-06-11 |