| NPI | 1598347742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 40295) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS106442) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-27 |
| Last Update Date | 2024-03-27 |