| NPI | 1386062917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN22899) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 0200000) |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2017-07-23 |