| NPI | 1336626589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30624) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D010016) |
| Enumeration Date | 2018-07-20 |
| Last Update Date | 2022-08-01 |