| NPI | 1114622669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 17884) |
| Enumeration Date | 2023-04-04 |
| Last Update Date | 2024-03-25 |