| 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 |