| NPI | 1861897548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 108622) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 6568) |
| 122300000X Dentist (Licence: NV 6568) | |
| Enumeration Date | 2014-10-24 |
| Last Update Date | 2024-01-03 |