| NPI | 1376275545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MD 18344) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401419342) | |
| Enumeration Date | 2022-06-27 |
| Last Update Date | 2025-05-05 |