| NPI | 1871805291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30311) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: AZ D008686) |
| Enumeration Date | 2010-07-14 |
| Last Update Date | 2013-05-20 |