| NPI | 1841645231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10652) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 135501) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-05-04 |
| Last Update Date | 2018-10-24 |