| NPI | 1043803612 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 14031) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: GA DN122889) | 
| Enumeration Date | 2021-02-15 | 
| Last Update Date | 2025-10-02 |