| NPI | 1629507488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MN D14668) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 019031135) |
| Enumeration Date | 2017-06-06 |
| Last Update Date | 2023-10-16 |