NPI | 1063870483 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859541) |
Additional Taxonomies | 122300000X Dentist (Licence: CA 100962) |
390200000X Student in an Organized Health Care Education/Training Program | |
Enumeration Date | 2016-01-29 |
Last Update Date | 2023-06-16 |