| NPI | 1710146394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MN D12818) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 2728) |
| Enumeration Date | 2008-06-09 |
| Last Update Date | 2014-01-14 |