| NPI | 1659725869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN22257) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 261QM2500X Clinic/Center, Medical Specialty (Licence: FL DN22257) | |
| Enumeration Date | 2016-04-14 |
| Last Update Date | 2020-09-17 |