| NPI | 1083319776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 14139) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 10850) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2025-07-14 |