| NPI | 1720540818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D11588) |
| Additional Taxonomies | 1223D0001X Dentist Dental Public Health (Licence: CA 105104) |
| Enumeration Date | 2019-04-05 |
| Last Update Date | 2022-09-16 |