| NPI | 1912491705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 34860) |
| Enumeration Date | 2018-06-15 |
| Last Update Date | 2022-04-04 |