| NPI | 1114367414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TN DS0000010263) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH RES.3338) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30413) | |
| Enumeration Date | 2013-07-01 |
| Last Update Date | 2016-08-17 |