| NPI | 1114260239 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: PA DS041422) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MA DL12231) | |
| Enumeration Date | 2013-03-27 |
| Last Update Date | 2018-09-27 |