| NPI | 1477075125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416462) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN1001753) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2022-01-17 |