| NPI | 1861957672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS104762) |
| Additional Taxonomies | 122300000X Dentist (Licence: VT 016.0133877) |
| Enumeration Date | 2019-02-06 |
| Last Update Date | 2022-01-28 |