| NPI | 1114418704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA DDS107636) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD4982) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-110) | |
| Enumeration Date | 2018-05-20 |
| Last Update Date | 2023-06-01 |