| NPI | 1154860849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 103701) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: NY 059863) | |
| Enumeration Date | 2017-02-15 |
| Last Update Date | 2019-10-28 |