| NPI | 1659881100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: CA 55373) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 55373) |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2018-10-15 |