| NPI | 1770100372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 107219) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858718) |
| Enumeration Date | 2020-06-30 |
| Last Update Date | 2022-07-20 |