| NPI | 1730815309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 107665) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 107665) |
| Enumeration Date | 2022-07-26 |
| Last Update Date | 2023-03-27 |