| NPI | 1861898603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 39759) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: FL TP755) | |
| Enumeration Date | 2014-11-05 |
| Last Update Date | 2024-01-23 |