| NPI | 1902327026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA DDS106093) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857665) |
| Enumeration Date | 2017-06-28 |
| Last Update Date | 2021-04-27 |