| NPI | 1215354600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4113) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: WI 7245-15) | |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2014-10-22 |