| NPI | 1013586866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D012728) |
| 122300000X Dentist (Licence: OH 30.027383) | |
| Enumeration Date | 2021-06-24 |
| Last Update Date | 2026-02-20 |