| NPI | 1811315567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4134) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM DD4134) |
| Enumeration Date | 2014-03-31 |
| Last Update Date | 2020-08-07 |