| NPI | 1700063666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: VA 0401412715) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0442000074) |
| Enumeration Date | 2008-01-23 |
| Last Update Date | 2010-03-25 |