| NPI | 1659534253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 24118) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24118) |
| 1223G0001X Dentist, General Practice (Licence: TX 24118) | |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2011-06-22 |