| NPI | 1417335258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OK 220) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OK 6693) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30446) | |
| Enumeration Date | 2015-05-13 |
| Last Update Date | 2017-11-15 |