| NPI | 1588272645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 11809477-9922) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 11809477-9922) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-07-15 |
| Last Update Date | 2025-11-04 |