| NPI | 1972711364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 28893) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 28893) |
| Enumeration Date | 2007-05-18 |
| Last Update Date | 2025-04-16 |