| NPI | 1730561614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 10132) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MI 2901022421) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-06-26 |
| Last Update Date | 2018-06-21 |