| NPI | 1760053540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951000972) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-5291) |
| Enumeration Date | 2021-07-02 |
| Last Update Date | 2024-07-02 |