| NPI | 1164115515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: OH APP-000720856) |
| Enumeration Date | 2023-05-31 |
| Last Update Date | 2023-09-21 |