| NPI | 1679181846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 13153) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858759) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-07-14 |
| Last Update Date | 2024-07-24 |