| NPI | 1669097986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 40001) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WI 1002325-15) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-06-11 |
| Last Update Date | 2023-11-01 |