| NPI | 1548904089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2951000897) |
| Additional Taxonomies | 1223E0200X Dentist, Endodontics (Licence: OH 30.027179) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-04-21 |
| Last Update Date | 2023-06-11 |