| NPI | 1114422383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: SC 9228) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: SC 9228) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-28 |
| Last Update Date | 2021-09-07 |