| NPI | 1104008861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 24489) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX N6417) |
| Enumeration Date | 2007-12-04 |
| Last Update Date | 2011-12-07 |