| NPI | 1649854373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123576) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 108003) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-05-10 |
| Last Update Date | 2025-08-05 |