| NPI | 1992303119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 105666) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 106555) |
| Enumeration Date | 2020-10-09 |
| Last Update Date | 2020-10-15 |