| NPI | 1467896571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 29747) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: WI 7125-15) | |
| Enumeration Date | 2013-04-18 |
| Last Update Date | 2015-09-26 |