| NPI | 1902535826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY D-00161) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2022018759) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO 2022018759) | |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2026-08-28 |