| NPI | 1720373897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CO 00203015) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 60429) |
| Enumeration Date | 2011-06-16 |
| Last Update Date | 2022-07-21 |