| NPI | 1497243190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MI 2901600343) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 2901600343) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-27 |
| Last Update Date | 2021-06-04 |