| NPI | 1639713746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA A204372) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D11176) |
| Enumeration Date | 2019-10-31 |
| Last Update Date | 2025-09-05 |