| NPI | 1720494370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WI 1002288-15) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 30209) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 059610) | |
| Enumeration Date | 2014-07-03 |
| Last Update Date | 2021-03-26 |