| NPI | 1205551157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901601477) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601477) |
| Enumeration Date | 2022-10-04 |
| Last Update Date | 2023-09-06 |