| NPI | 1538780051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30704) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14499) |
| Enumeration Date | 2020-05-06 |
| Last Update Date | 2025-05-13 |