| NPI | 1508078858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PR 2756) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: GA 390200000x) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2007-07-08 |