| NPI | 1255711693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001434) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: TX 31576) | |
| Enumeration Date | 2015-06-01 |
| Last Update Date | 2016-11-23 |