NPI | 1124763826 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 122300000X Dentist (Licence: TX 38763) |
Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 38763) |
390200000X Student in an Organized Health Care Education/Training Program | |
Enumeration Date | 2022-04-28 |
Last Update Date | 2023-08-10 |