| NPI | 1710255971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 103580) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9127) |
| Enumeration Date | 2011-12-02 |
| Last Update Date | 2023-10-20 |