| NPI | 1659727535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10958) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 10574) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-05-10 |
| Last Update Date | 2019-10-21 |