| NPI | 1073957361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NE 32000) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 30968) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 30968) | |
| Enumeration Date | 2013-04-17 |
| Last Update Date | 2020-02-07 |