| NPI | 1124517735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35543) |
| Additional Taxonomies | 122300000X Dentist (Licence: MS 4007-18) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-05-09 |
| Last Update Date | 2024-02-12 |