| NPI | 1255909701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 12773533-9922) |
| Enumeration Date | 2021-06-11 |
| Last Update Date | 2022-07-26 |