| NPI | 1619201761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901022036) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2009-09-22 |
| Last Update Date | 2016-07-13 |