| NPI | 1497139745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: TX 31006) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 31006) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 31006) | |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2026-06-25 |