| NPI | 1609443720 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 125Q00000X Oral Medicine (Licence: MA DL14962) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2021-06-08 | 
| Last Update Date | 2025-05-12 |