| NPI | 1225684160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901602514) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 35679) |
| Enumeration Date | 2019-08-15 |
| Last Update Date | 2025-08-06 |