| NPI | 1003909508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30363) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 6643-15) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2013-02-20 |