| NPI | 1003459355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901602938) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 35770) |
| Enumeration Date | 2019-10-18 |
| Last Update Date | 2026-05-31 |