NPI | 1730659459 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 107551) |
Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858728) |
390200000X Student in an Organized Health Care Education/Training Program | |
Enumeration Date | 2018-11-26 |
Last Update Date | 2023-07-28 |