| NPI | 1790101244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: CA GA1703) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62252) |
| Enumeration Date | 2014-03-07 |
| Last Update Date | 2025-04-23 |