| NPI | 1063790194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 60426) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 60426) |
| Enumeration Date | 2011-07-22 |
| Last Update Date | 2016-09-21 |