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 |