| NPI | 1811412059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 105659) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857720) |
| Enumeration Date | 2017-08-09 |
| Last Update Date | 2022-07-21 |