| NPI | 1700491891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 105532) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 105532) |
| Enumeration Date | 2020-09-15 |
| Last Update Date | 2021-02-10 |