| NPI | 1548059652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 30.027925) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.027925) |
| 1223G0001X Dentist, General Practice (Licence: OH 30.027925) | |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2025-05-05 |
| Last Update Date | 2025-08-07 |