| NPI | 1790213486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 061661) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 6924) |
| Enumeration Date | 2017-05-25 |
| Last Update Date | 2021-06-22 |