| NPI | 1902482920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122418) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901600872) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-21 |
| Last Update Date | 2022-05-18 |