| NPI | 1861955726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 114255239921) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 35660) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-08 |
| Last Update Date | 2025-05-07 |