| NPI | 1922594381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 102635) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 102635) |
| Enumeration Date | 2018-07-09 |
| Last Update Date | 2021-06-10 |