| NPI | 1992360705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011424) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 103901) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-05-07 |
| Last Update Date | 2025-01-06 |