| NPI | 1518696806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 12879487-9922) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: UT 12879487-9922) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2023-08-22 |