| NPI | 1033658406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0438000489) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0401415733) |
| Enumeration Date | 2017-02-18 |
| Last Update Date | 2023-09-11 |