| NPI | 1588240766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.0020505466) |
| Enumeration Date | 2021-03-19 |
| Last Update Date | 2023-11-19 |