| NPI | 1144600289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 105586) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041118) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA 3902000000X) | |
| Enumeration Date | 2015-06-03 |
| Last Update Date | 2021-01-12 |