| NPI | 1790154342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 104416) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 104416) |
| 122300000X Dentist (Licence: MO 2015032017) | |
| Enumeration Date | 2015-09-24 |
| Last Update Date | 2020-06-26 |