| NPI | 1386093219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: ID D-5193-OR) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD5108) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-06-10 |
| Last Update Date | 2021-05-05 |