| NPI | 1942567466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 711815) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30353) |
| Enumeration Date | 2012-04-22 |
| Last Update Date | 2015-12-08 |