| NPI | 1205100815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN d13136) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: 1) |
| Enumeration Date | 2012-02-28 |
| Last Update Date | 2019-12-04 |