| NPI | 1417444332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14478) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1002470) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-16 |
| Last Update Date | 2024-02-12 |