| NPI | 1700630035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS111721) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN123423) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-04-15 |
| Last Update Date | 2025-09-01 |