| NPI | 1770196024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 105025) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 105025) |
| Enumeration Date | 2020-08-26 |
| Last Update Date | 2022-04-27 |