| NPI | 1265929640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 6159362-9922) |
| Additional Taxonomies | 1223D0001X Dentist Dental Public Health (Licence: UT 6159362-9922) |
| 1223G0001X Dentist General Practice (Licence: UT 6159362-9922) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-20 |
| Last Update Date | 2020-09-12 |