| NPI | 1790213486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: UT 142031539924) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 6924) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 061661) | |
| Enumeration Date | 2017-05-25 |
| Last Update Date | 2026-01-29 |