| NPI | 1124697941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA 109947) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 11625) |
| Enumeration Date | 2021-06-24 |
| Last Update Date | 2026-05-24 |