| NPI | 1790137073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ID D-4761) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 100836) |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2018-06-25 |