| NPI | 1033782727 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951001006) | 
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 12326483-9922) | 
| Enumeration Date | 2021-07-20 | 
| Last Update Date | 2025-08-26 |