| NPI | 1124644604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 39920) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 12797) |
| Enumeration Date | 2020-06-22 |
| Last Update Date | 2023-08-22 |