| NPI | 1184246647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WI 6001155) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417811) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0442000385) | |
| Enumeration Date | 2020-05-07 |
| Last Update Date | 2023-08-15 |