| NPI | 1306406566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00204913) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D010866) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-06-19 |
| Last Update Date | 2026-04-21 |