| NPI | 1891374187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2022014444) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 37546) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-05 |
| Last Update Date | 2024-03-14 |