| NPI | 1770894701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 7919446-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10461) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-06-24 |
| Last Update Date | 2023-03-13 |