| NPI | 1548612617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA 0401416133) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 12362) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-12 |
| Last Update Date | 2023-09-28 |