| NPI | 1841467586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DE G1-0001281) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: SC 100123785) |
| Enumeration Date | 2008-05-12 |
| Last Update Date | 2020-02-18 |