| NPI | 1104185784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA DDS103801) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 056876) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MN R670) | |
| Enumeration Date | 2012-05-16 |
| Last Update Date | 2019-07-02 |