| NPI | 1013442078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: SC 2021) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 33481) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-27 |
| Last Update Date | 2022-05-17 |