| NPI | 1770572877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 56794) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MN D12148) |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2022-07-21 |