| NPI | 1700141454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: AZ D008482) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D008482) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 058435) | |
| Enumeration Date | 2012-07-09 |
| Last Update Date | 2018-06-29 |