| NPI | 1366858003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202300) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D010132) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-07-02 |
| Last Update Date | 2022-08-24 |