| NPI | 1417453077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN23525) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 23525) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2025-08-27 |