| NPI | 1588308464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX ETN925) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX ETN925) |
| Enumeration Date | 2022-04-26 |
| Last Update Date | 2025-08-22 |