| NPI | 1164160966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859710) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS043602) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-23 |
| Last Update Date | 2023-05-17 |