| NPI | 1184396004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS044483) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: SC 10044) | |
| 122300000X Dentist (Licence: TX 38876) | |
| Enumeration Date | 2021-09-29 |
| Last Update Date | 2025-07-23 |