| NPI | 1902467475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 110312) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 35208) |
| Enumeration Date | 2019-06-25 |
| Last Update Date | 2024-07-18 |