| NPI | 1235752189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858732) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN25348) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-05-27 |
| Last Update Date | 2021-03-21 |