| NPI | 1285246058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 13014) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 17721) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-08-21 |
| Last Update Date | 2023-12-19 |