| NPI | 1194404665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30679) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KS 62120) |
| Enumeration Date | 2023-07-12 |
| Last Update Date | 2024-05-08 |