| NPI | 1992196828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN21167) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: VA 0401415133) | |
| Enumeration Date | 2015-02-13 |
| Last Update Date | 2016-09-23 |