| NPI | 1912376872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: TX 40402) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30449) |
| Enumeration Date | 2015-09-22 |
| Last Update Date | 2026-03-27 |