| NPI | 1063198513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA DS044751) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 110187) |
| 122300000X Dentist (Licence: MO 2023025122) | |
| Enumeration Date | 2023-06-27 |
| Last Update Date | 2024-06-27 |