| NPI | 1699398404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL DN29908) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 000204395) |
| Enumeration Date | 2020-05-27 |
| Last Update Date | 2025-06-30 |