| NPI | 1558942276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: VA 0401419223) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0401419223) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2952000753) | |
| Enumeration Date | 2021-04-15 |
| Last Update Date | 2024-12-06 |