| NPI | 1639833544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 108467) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 61095542) |
| Enumeration Date | 2021-10-26 |
| Last Update Date | 2023-01-25 |