| NPI | 1134752637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.026099) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601097) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-02-13 |
| Last Update Date | 2022-05-19 |