| NPI | 1407782964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0442000596) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401420311) |
| Enumeration Date | 2026-06-22 |
| Last Update Date | 2026-09-30 |