| NPI | 1851767065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 105676) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 151064) |
| 1223P0300X Dentist, Periodontics (Licence: MO 202102186) | |
| Enumeration Date | 2015-08-12 |
| Last Update Date | 2021-07-22 |