| NPI | 1730619685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: PR 3265) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PR 3265) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2022-08-18 |