| NPI | 1790902989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA DDS106044) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019099) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901019099) | |
| Enumeration Date | 2007-04-19 |
| Last Update Date | 2022-05-31 |