| NPI | 1811656994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 106677) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D011601) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401417699) | |
| Enumeration Date | 2021-12-15 |
| Last Update Date | 2022-11-15 |