| NPI | 1336732692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 38273) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901600871) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-02-18 |
| Last Update Date | 2022-08-11 |