| NPI | 1699389015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MI 2901601899) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MA DL14982) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-09-02 |
| Last Update Date | 2023-08-29 |