| NPI | 1699157602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 103677) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA DL12597) |
| 1223G0001X Dentist, General Practice (Licence: CT 11688) | |
| Enumeration Date | 2015-06-25 |
| Last Update Date | 2019-11-20 |