| NPI | 1447882303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: UT 132148909924) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SC 9712) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-02-09 |
| Last Update Date | 2023-12-01 |