| NPI | 1669561114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 46874) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 200579547) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2021-11-17 |