| NPI | 1548721541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951000997) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D010758) |
| Enumeration Date | 2019-03-31 |
| Last Update Date | 2025-08-26 |