| NPI | 1861702557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS101101) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60189165) |
| Enumeration Date | 2010-10-14 |
| Last Update Date | 2023-08-07 |