| NPI | 1871077750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 103179) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 34587) |
| Enumeration Date | 2018-09-18 |
| Last Update Date | 2022-01-06 |