| NPI | 1487270799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 10440) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10440) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: KY 10440) | |
| Enumeration Date | 2020-06-23 |
| Last Update Date | 2025-08-01 |