| NPI | 1851659031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA DS040245) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9213) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-04-25 |
| Last Update Date | 2022-07-21 |