| NPI | 1922847763 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA DS045313) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 110988) |
| 122300000X Dentist (Licence: TX 40709) | |
| Enumeration Date | 2024-05-21 |
| Last Update Date | 2025-07-19 |