| NPI | 1235617283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 13747) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 13619) |
| Enumeration Date | 2018-08-01 |
| Last Update Date | 2023-05-19 |