| NPI | 1003784810 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA DL101029) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DL101029) |
| Enumeration Date | 2025-10-24 |
| Last Update Date | 2025-10-24 |