| NPI | 1336528264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS100774) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058784) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-05-26 |
| Last Update Date | 2016-09-26 |