| NPI | 1710500954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 107752) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.026591) |
| Enumeration Date | 2020-05-22 |
| Last Update Date | 2023-10-29 |