| NPI | 1912347253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WY 1343) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NE 7089) |
| 122300000X Dentist (Licence: NE 7089) | |
| Enumeration Date | 2013-07-01 |
| Last Update Date | 2016-01-25 |