| NPI | 1720570088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00203859) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-107) |
| Enumeration Date | 2018-06-02 |
| Last Update Date | 2020-03-16 |