| NPI | 1700599735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ME DEN5049) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: CO DEN.00206562) | |
| Enumeration Date | 2023-01-04 |
| Last Update Date | 2026-03-15 |