| NPI | 1679554976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 48090) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 60288004) |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2022-03-17 |