| NPI | 1619596590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN26497) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN122506) |
| 122300000X Dentist (Licence: AL D6950-C1) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-10 |
| Last Update Date | 2023-09-14 |