| NPI | 1689295008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 105202) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 14402) |
| Enumeration Date | 2020-04-27 |
| Last Update Date | 2026-04-14 |