| NPI | 1871158329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 13150075) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.026249) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-112) | |
| Enumeration Date | 2019-05-09 |
| Last Update Date | 2023-08-16 |