| NPI | 1063753838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 12446) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 12446) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-03-04 |
| Last Update Date | 2019-10-15 |