| NPI | 1962104901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 14088) |
| Additional Taxonomies | 122300000X Dentist (Licence: IN 12014063A) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2025-04-16 |