| NPI | 1164879680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN29342) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL100073) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 12000) | |
| Enumeration Date | 2016-05-16 |
| Last Update Date | 2026-04-06 |