| NPI | 1023507878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35751) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1857943) |
| 122300000X Dentist (Licence: LA 7772) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-05-08 |
| Last Update Date | 2026-05-27 |