| NPI | 1427516095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1539) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-116) |
| Enumeration Date | 2019-03-03 |
| Last Update Date | 2020-05-22 |