| NPI | 1770165862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NE 7988) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-09911) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA DDS-09911) | |
| 122300000X Dentist (Licence: MN D14662) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-27 |
| Last Update Date | 2024-06-17 |