| NPI | 1235506601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AL D.007315) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00204322) |
| 122300000X Dentist (Licence: AZ D011217) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-129) | |
| Enumeration Date | 2015-09-01 |
| Last Update Date | 2024-06-04 |