| NPI | 1316458797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ 012632) |
| Additional Taxonomies | 103K00000X Behavior Analyst |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-10-12 |
| Last Update Date | 2026-01-08 |