| NPI | 1659755189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2015021494) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS105564) |
| 122300000X Dentist (Licence: MO 2020030635) | |
| 122300000X Dentist (Licence: WA 60509168) | |
| 122300000X Dentist (Licence: IL 019.030501) | |
| Enumeration Date | 2015-07-14 |
| Last Update Date | 2021-11-02 |