| NPI | 1891085676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901020585) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 6686-15) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-04-13 |
| Last Update Date | 2019-06-25 |