| NPI | 1821677964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011952) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 7215) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-06 |
| Last Update Date | 2023-10-06 |