| NPI | 1558864140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ 10177) |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: AZ 10177) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-09 |
| Last Update Date | 2021-10-12 |