| NPI | 1184964710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 65040) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: OH 30-024260) | |
| Enumeration Date | 2013-02-19 |
| Last Update Date | 2015-08-28 |