| NPI | 1780678466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: IA 05935) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 23154) |
| 122300000X Dentist (Licence: WI 5000989015) | |
| Enumeration Date | 2005-09-08 |
| Last Update Date | 2026-03-27 |