| NPI | 1669461802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 58091) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN d11992) |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2021-05-25 |