| NPI | 1093454639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859477) |
| Additional Taxonomies | 122300000X Dentist (Licence: AR 4633) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-06-01 |
| Last Update Date | 2024-01-01 |