| NPI | 1811485352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00204543) |
| Additional Taxonomies | 122300000X Dentist (Licence: AL 6593-C1) |
| 122300000X Dentist (Licence: TX 34227) | |
| 122300000X Dentist (Licence: OK 7597) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-30 |
| Last Update Date | 2022-05-10 |