| NPI | 1760916092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 9132) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN015458) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-13 |
| Last Update Date | 2019-10-08 |