| NPI | 1235571316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: MN D13305) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13305) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30486) | |
| Enumeration Date | 2013-07-18 |
| Last Update Date | 2022-07-21 |