| NPI | 1215338850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415584) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 20928) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30447) | |
| Enumeration Date | 2014-09-15 |
| Last Update Date | 2020-09-01 |