| NPI | 1598450546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951001039) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 41635) |
| Enumeration Date | 2023-04-06 |
| Last Update Date | 2026-07-08 |