| NPI | 1164164232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 38524) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-151) | |
| Enumeration Date | 2022-04-10 |
| Last Update Date | 2023-05-19 |