| NPI | 1386273647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL15820) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 106847) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2023-11-27 |