| NPI | 1255622635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: CO DEN.00203857) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 8020326-9924) |
| 1223G0001X Dentist, General Practice (Licence: UT 8020326-9921) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-04-20 |
| Last Update Date | 2019-07-27 |