| NPI | 1255855904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: UT 12879938-9923) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS101595) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-08-02 |
| Last Update Date | 2024-08-01 |