| NPI | 1679146823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 111424) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 13221) |
| Enumeration Date | 2021-07-23 |
| Last Update Date | 2025-07-09 |