| NPI | 1073194270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12873) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: WI 1002613-15) | |
| Enumeration Date | 2021-04-19 |
| Last Update Date | 2025-11-17 |