| NPI | 1073800520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MO 2018010876) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: FL DN 21761) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-07-06 |
| Last Update Date | 2019-01-18 |