| NPI | 1861700932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DX038451) |
| Enumeration Date | 2010-09-22 |
| Last Update Date | 2011-06-03 |