| NPI | 1124702162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN124002) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: PR 117R) | |
| Enumeration Date | 2023-06-12 |
| Last Update Date | 2026-03-07 |