| NPI | 1790920916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 23956) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 23956) |
| Enumeration Date | 2008-12-03 |
| Last Update Date | 2009-09-29 |