| NPI | 1306636204 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NC 14348) |
| Enumeration Date | 2025-05-12 |
| Last Update Date | 2025-07-18 |