| NPI | 1851980650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2951001003) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1002494-15) |
| Enumeration Date | 2021-01-15 |
| Last Update Date | 2025-07-11 |