| NPI | 1568868149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 63276) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 126) |
| 1223G0001X Dentist, General Practice (Licence: NE 126) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NE 126) | |
| Enumeration Date | 2014-11-10 |
| Last Update Date | 2020-12-14 |