| NPI | 1609443514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 7551) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 123777069921) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-06-09 |
| Last Update Date | 2024-07-10 |