| NPI | 1689075764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 45864) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NC 12393) |
| Enumeration Date | 2014-09-09 |
| Last Update Date | 2024-04-01 |