| NPI | 1700512456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS109896) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601517) |
| Enumeration Date | 2022-07-26 |
| Last Update Date | 2025-01-07 |