| NPI | 1659981447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 105088) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA DDS105088) |
| Enumeration Date | 2020-08-05 |
| Last Update Date | 2020-11-17 |