| NPI | 1346703501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 14766) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 14848) |
| Enumeration Date | 2019-04-12 |
| Last Update Date | 2026-07-21 |