| NPI | 1326328600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NE 6983) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 6983) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NE 6983) | |
| Enumeration Date | 2011-08-18 |
| Last Update Date | 2011-08-18 |