| NPI | 1619591732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA RES-30734) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D010676) |
| Enumeration Date | 2020-06-04 |
| Last Update Date | 2026-05-22 |