| NPI | 1033472048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30683) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9195) |
| Enumeration Date | 2012-06-25 |
| Last Update Date | 2025-08-27 |