| NPI | 1346707007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14840) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1002057) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-02-28 |
| Last Update Date | 2023-12-07 |