| NPI | 1851852016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN24624) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 018.002100) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2020-08-12 |