| NPI | 1841612744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401415145) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: PA DS039841) | |
| Enumeration Date | 2014-01-10 |
| Last Update Date | 2016-08-01 |