| NPI | 1013558519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12591) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 9594) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-10-05 |
| Last Update Date | 2022-03-13 |