| NPI | 1679931307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 23885) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN015313) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-02-09 |
| Last Update Date | 2022-02-07 |