| NPI | 1730560483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: MN D14032) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857141) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-06-17 |
| Last Update Date | 2018-06-18 |