| NPI | 1104285543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CO DEN.00205787) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO DEN.00205787) | |
| Enumeration Date | 2016-02-13 |
| Last Update Date | 2023-10-17 |