| NPI | 1033553771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: VA 0401414282) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401414282) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30417) | |
| Enumeration Date | 2013-04-24 |
| Last Update Date | 2019-01-31 |