| NPI | 1790130821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: CA DDS102682) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60656563) |
| 122300000X Dentist (Licence: CA DDS102682) | |
| Enumeration Date | 2016-04-26 |
| Last Update Date | 2022-02-10 |