| NPI | 1629574066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 11741) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 9614) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-04 |
| Last Update Date | 2020-07-30 |