| NPI | 1639752256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011625) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: SC 9941) | |
| Enumeration Date | 2021-05-02 |
| Last Update Date | 2023-06-01 |