| NPI | 1972624997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 39347) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 39347) |
| Enumeration Date | 2007-04-03 |
| Last Update Date | 2021-10-07 |