| NPI | 1104352699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 13445134-9922) |
| Additional Taxonomies | 101Y00000X Counselor |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: UT 13445134-9922) | |
| Enumeration Date | 2017-05-04 |
| Last Update Date | 2023-08-10 |