| NPI | 1790096154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: CA DDS61391) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855461) |
| Enumeration Date | 2010-06-30 |
| Last Update Date | 2021-12-10 |