| NPI | 1083350201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MD 17805) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: MD 17805) | |
| Enumeration Date | 2022-05-10 |
| Last Update Date | 2026-07-14 |