| NPI | 1417576372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: FL DN25716) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN25716) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-10 |
| Last Update Date | 2023-08-14 |