| NPI | 1215560792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 11790) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 11790) |
| Enumeration Date | 2020-02-12 |
| Last Update Date | 2021-08-04 |