| NPI | 1700522133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MO 2025018029) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601445) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-09 |
| Last Update Date | 2025-08-15 |