| NPI | 1003367293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 10081) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100587) |
| Enumeration Date | 2016-10-22 |
| Last Update Date | 2023-06-26 |