| NPI | 1386091791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CO DEN.00203453) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 32469) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 21898304) | |
| Enumeration Date | 2016-05-16 |
| Last Update Date | 2020-02-19 |