| NPI | 1861194706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: FL 28387) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901601892) |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2026-05-13 |