| NPI | 1578981288 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KS 61152) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 61152) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-03-31 |
| Last Update Date | 2017-10-11 |