| NPI | 1215318969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858962) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: CO DEN.00202834) | |
| Enumeration Date | 2015-06-17 |
| Last Update Date | 2022-01-05 |