| NPI | 1013569144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 14070) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 103936) |
| 122300000X Dentist (Licence: TX 35694) | |
| Enumeration Date | 2019-07-09 |
| Last Update Date | 2024-06-05 |