| NPI | 1013396365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31913) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 058506) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-05-20 |
| Last Update Date | 2019-12-10 |