| NPI | 1568107027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: ID 1771556) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 7664) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NV 7664) | |
| Enumeration Date | 2022-04-29 |
| Last Update Date | 2025-04-24 |