| NPI | 1861807042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60469714) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4419) |
| 122300000X Dentist (Licence: WA DE60469714) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-06-25 |
| Last Update Date | 2021-06-26 |