| NPI | 1194217166 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901602634) | 
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019031843) | 
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901602634) | |
| Enumeration Date | 2018-06-05 | 
| Last Update Date | 2025-09-02 |