| NPI | 1851750400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 104758) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR D10620) |
| 1223G0001X Dentist General Practice (Licence: AZ D9973) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-02-10 |
| Last Update Date | 2023-06-08 |