| NPI | 1760053540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901602494) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951000972) |
| 1223G0001X Dentist, General Practice (Licence: ID D-5291) | |
| Enumeration Date | 2021-07-02 |
| Last Update Date | 2025-08-13 |