| NPI | 1619170818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ID 4465) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 48663) |
| Enumeration Date | 2007-06-06 |
| Last Update Date | 2024-02-28 |