| NPI | 1679278311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: IL 019.035360) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 018.002259) |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2025-04-18 |