| NPI | 1326427477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MI 2901601179) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024928) |
| 208D00000X General Practice (Licence: MI 4301504167) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2022-10-12 |