| NPI | 1396438552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 42845) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30662) | |
| Enumeration Date | 2023-06-01 |
| Last Update Date | 2026-08-20 |