| NPI | 1699049627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MN R668) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7015) |
| Enumeration Date | 2012-03-08 |
| Last Update Date | 2022-07-21 |