| NPI | 1578097044 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: FL D26263) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041412) |
| 1223G0001X Dentist General Practice (Licence: AL D.0006693-C1) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-12 |
| Last Update Date | 2021-10-07 |