| NPI | 1629403522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 101258) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 29470) |
| Enumeration Date | 2013-09-10 |
| Last Update Date | 2022-07-21 |