| NPI | 1750964938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 106150) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 61138583) |
| Enumeration Date | 2021-05-04 |
| Last Update Date | 2021-05-13 |