| NPI | 1578089389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA DS041449) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041449) |
| Enumeration Date | 2017-08-15 |
| Last Update Date | 2026-07-17 |