| NPI | 1720106198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12430) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 46632) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2022-01-13 |