| NPI | 1407589344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601632) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX ETN960) |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2023-07-21 |