| NPI | 1720970395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 151482) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 151482) |
| Enumeration Date | 2025-07-17 |
| Last Update Date | 2025-09-08 |