| NPI | 1235598632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10589) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 31445880) |
| Enumeration Date | 2016-02-15 |
| Last Update Date | 2017-05-05 |