| NPI | 1386392629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 12842) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 12842) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-03-15 |
| Last Update Date | 2023-05-25 |