| NPI | 1972156784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 39140) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 3259709) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-07-21 |
| Last Update Date | 2022-10-17 |