| NPI | 1669907663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 107810) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022211) |
| Enumeration Date | 2017-04-27 |
| Last Update Date | 2022-08-19 |