| NPI | 1356080139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951000923) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 7319) |
| Enumeration Date | 2022-06-01 |
| Last Update Date | 2023-06-27 |