| NPI | 1164876280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 10153) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA DE60647135) |
| Enumeration Date | 2016-04-14 |
| Last Update Date | 2022-08-11 |