| NPI | 1104316074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: PA DS041737) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MT224239) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-05-15 |
| Last Update Date | 2021-11-06 |