| NPI | 1609930700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 100078) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D12190) |
| Enumeration Date | 2006-12-21 |
| Last Update Date | 2019-05-09 |