| NPI | 1780357335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 107202) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417605) |
| Enumeration Date | 2021-07-29 |
| Last Update Date | 2021-12-27 |