| NPI | 1083076764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 101923) |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2016-03-22 |
| Last Update Date | 2018-07-10 |