| NPI | 1124498779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ME FDN23) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30451) |
| Enumeration Date | 2015-09-25 |
| Last Update Date | 2022-06-27 |