| NPI | 1275161754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951000934) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AZ D011158) |
| Enumeration Date | 2020-03-30 |
| Last Update Date | 2023-06-23 |