| NPI | 1659928034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D11227) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 104294) |
| Enumeration Date | 2019-08-21 |
| Last Update Date | 2020-06-16 |