| NPI | 1134686298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD5283) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-111) | |
| Enumeration Date | 2019-02-25 |
| Last Update Date | 2020-11-03 |