| NPI | 1396919106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD3103) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223D0001X Dentist, Dental Public Health (Licence: NM DD3103) | |
| Enumeration Date | 2008-04-14 |
| Last Update Date | 2015-03-30 |