| NPI | 1689164816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2019007234) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10147) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-05-14 |
| Last Update Date | 2020-12-19 |