| NPI | 1265274245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: UT 14033597) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 14033597-9926) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-06-10 |
| Last Update Date | 2025-06-06 |