| NPI | 1801589445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY 11091) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 11091) | |
| Enumeration Date | 2023-05-30 |
| Last Update Date | 2025-09-09 |