| NPI | 1386264455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS043847) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: 390200000X) |
| Enumeration Date | 2020-04-19 |
| Last Update Date | 2023-05-29 |