| NPI | 1710032552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 58992) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MN D12302) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2022-01-23 |