| NPI | 1568114775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12752) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental |
| 261QD0000X Clinic/Center, Dental | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-01-19 |
| Last Update Date | 2022-05-31 |