| NPI | 1982130233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 34896) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041280) |
| 1223G0001X Dentist General Practice (Licence: PA DS041280) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-05-05 |
| Last Update Date | 2021-12-28 |