| NPI | 1720467145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 102991) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 058909) |
| Enumeration Date | 2015-05-19 |
| Last Update Date | 2018-08-15 |