| NPI | 1043358039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30324) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY None) |
| 1223G0001X Dentist, General Practice (Licence: CA 58168) | |
| Enumeration Date | 2007-02-02 |
| Last Update Date | 2013-02-04 |