| NPI | 1396293940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401416722) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 36977) | |
| Enumeration Date | 2016-09-12 |
| Last Update Date | 2021-06-14 |