| NPI | 1164815759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MI 2901600783) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 11504) |
| 122300000X Dentist (Licence: MI 2901600783) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-03-06 |
| Last Update Date | 2023-07-31 |