| NPI | 1184249096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 25117) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 51271) |
| Enumeration Date | 2020-06-16 |
| Last Update Date | 2021-09-02 |