| NPI | 1114040060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 20534) |
| Enumeration Date | 2007-04-07 |
| Last Update Date | 2023-06-23 |