| NPI | 1467072892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-5308) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM TD-00-125) | |
| Enumeration Date | 2020-04-27 |
| Last Update Date | 2021-07-06 |