| NPI | 1205404084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 125Q00000X Oral Medicine (Licence: PA DS045618) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: MI 2951000846) | |
| Enumeration Date | 2021-06-16 |
| Last Update Date | 2026-06-15 |