| NPI | 1497097448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901022068) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: OH 30.025628) | |
| 122300000X Dentist (Licence: IL 019.032301) | |
| Enumeration Date | 2013-03-17 |
| Last Update Date | 2026-07-22 |