| NPI | 1992125488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 30638) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM #TD-00-64) |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2015-08-17 |