| NPI | 1013758994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2025052674) |
| Additional Taxonomies | 122300000X Dentist (Licence: PR 003529) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-06-04 |
| Last Update Date | 2026-05-19 |