| NPI | 1720440936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61286676) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.025200) |
| 122300000X Dentist (Licence: CA 103715) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-03-26 |
| Last Update Date | 2022-06-14 |