| NPI | 1396346912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 13111) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 13034) |
| 1223G0001X Dentist, General Practice (Licence: CA 105764) | |
| Enumeration Date | 2020-11-02 |
| Last Update Date | 2021-06-02 |