| NPI | 1518387158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D010190) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13411) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-04-22 |
| Last Update Date | 2019-01-02 |