| NPI | 1811563778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601926) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00204863) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901601926) | |
| Enumeration Date | 2021-06-01 |
| Last Update Date | 2024-06-26 |