| NPI | 1942056163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS045577) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: WI 6001486-15) | |
| Enumeration Date | 2024-04-29 |
| Last Update Date | 2026-04-06 |