| NPI | 1356722680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0700X Dentist Prosthodontics (Licence: VT 016.0133904) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 058774) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-06-11 |
| Last Update Date | 2019-08-13 |