| NPI | 1003063918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 55180) |
| Enumeration Date | 2008-08-21 |
| Last Update Date | 2012-01-24 |