| NPI | 1699495713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 111259) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1859577) |
| Enumeration Date | 2022-08-30 |
| Last Update Date | 2026-01-19 |