| NPI | 1609551100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL DN28943) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN28943) |
| Enumeration Date | 2023-06-21 |
| Last Update Date | 2026-06-05 |