| NPI | 1235516188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 23287) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: FL 23287) | |
| Enumeration Date | 2015-04-29 |
| Last Update Date | 2022-08-24 |