| NPI | 1265915672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30623) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.031783) |
| Enumeration Date | 2018-09-11 |
| Last Update Date | 2022-07-26 |