| NPI | 1508491564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 12887) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NH 04643) |
| Enumeration Date | 2020-03-10 |
| Last Update Date | 2021-05-25 |