| NPI | 1508356221 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 13919) |
| 122300000X Dentist (Licence: MO 2024020973) | |
| Enumeration Date | 2018-05-17 |
| Last Update Date | 2024-06-10 |