| NPI | 1700644788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS112688) |
| Enumeration Date | 2024-03-13 |
| Last Update Date | 2026-03-20 |