| NPI | 1801407010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 36744) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX ETN770) |
| Enumeration Date | 2020-08-11 |
| Last Update Date | 2022-08-02 |