| NPI | 1649962937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951000936) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2023-05-24 |
| Last Update Date | 2024-06-21 |