| NPI | 1356974513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 9721) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: SC DGD.9721GD) |
| Enumeration Date | 2020-02-17 |
| Last Update Date | 2025-01-06 |