| NPI | 1841701471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 33489) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 33489) |
| Enumeration Date | 2017-10-23 |
| Last Update Date | 2023-01-31 |