| NPI | 1952754467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 38771) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 12492) |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2022-07-21 |