| NPI | 1063917128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0401417844) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417844) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401417844) | |
| Enumeration Date | 2018-03-29 |
| Last Update Date | 2022-06-29 |