| NPI | 1740980473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 111027) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 40119) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-03-09 |
| Last Update Date | 2024-11-25 |