| NPI | 1336507862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN23173) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH RES.3656) |
| Enumeration Date | 2016-01-28 |
| Last Update Date | 2018-09-28 |