| NPI | 1053842195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 37471) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO den.00203892) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-03-21 |
| Last Update Date | 2024-01-17 |