| NPI | 1568021400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416646) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 17018) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-06-12 |
| Last Update Date | 2026-04-29 |