| NPI | 1750026720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN29474) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 2428) |
| Enumeration Date | 2022-05-03 |
| Last Update Date | 2024-10-25 |