| NPI | 1790169613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 102536) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 31453) |
| Enumeration Date | 2015-07-10 |
| Last Update Date | 2021-09-14 |