| NPI | 1780259176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 106159) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 106159) |
| Enumeration Date | 2021-05-26 |
| Last Update Date | 2024-03-10 |