| NPI | 1689175697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: TX 33973) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 33973) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-02-24 |
| Last Update Date | 2022-11-07 |