| NPI | 1578219291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601388) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: MI 22164130600) | |
| Enumeration Date | 2022-02-22 |
| Last Update Date | 2022-06-15 |