| NPI | 1720684061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2022023827) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 105865) |
| Enumeration Date | 2020-12-10 |
| Last Update Date | 2022-07-29 |