| NPI | 1639767155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 105161) |
| Enumeration Date | 2021-01-10 |
| Last Update Date | 2023-04-13 |