| NPI | 1609322965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CT 13058) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901021812) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901021812) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901021812) | |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2021-05-03 |