| NPI | 1780204693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 10456) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901602913) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-21 |
| Last Update Date | 2026-04-05 |