| NPI | 1790200160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: NC 10957) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 101809) |
| Enumeration Date | 2017-08-07 |
| Last Update Date | 2021-06-30 |