| NPI | 1144975681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2024025185) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.027061) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: OH 30.027061) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-02-14 |
| Last Update Date | 2024-06-27 |