| NPI | 1457738833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00204911) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: DE 1) |
| Enumeration Date | 2015-05-05 |
| Last Update Date | 2022-07-21 |