| NPI | 1104379718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 103082) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 7356) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-31 |
| Last Update Date | 2023-07-26 |