| NPI | 1366836835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR 10985) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ D009666) | |
| Enumeration Date | 2015-03-23 |
| Last Update Date | 2019-07-19 |