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 |