| NPI | 1114719937 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6001832-15) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2025-05-19 |
| Last Update Date | 2025-06-03 |