| NPI | 1407413180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901600195) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.025831) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2024-07-15 |