| NPI | 1023688322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 14066) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS043439) |
| Enumeration Date | 2021-06-29 |
| Last Update Date | 2024-06-11 |