| NPI | 1497318596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: LA S-992) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 36745) |
| Enumeration Date | 2019-04-16 |
| Last Update Date | 2022-06-09 |