| NPI | 1467912543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951001041) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 105579) |
| Enumeration Date | 2019-03-23 |
| Last Update Date | 2026-07-23 |