| NPI | 1912487265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: MN R862) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS102908) |
| Enumeration Date | 2018-08-16 |
| Last Update Date | 2023-06-27 |