| NPI | 1518313345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN23389) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 1516) |
| Enumeration Date | 2016-05-11 |
| Last Update Date | 2022-02-22 |