| NPI | 1871294272 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901601650) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2023-03-13 | 
| Last Update Date | 2025-09-08 |