| NPI | 1104387117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 03947) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC TBD) | |
| Enumeration Date | 2019-03-31 |
| Last Update Date | 2026-03-16 |