| NPI | 1154687770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: LA 6265) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DE60732399) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-04-09 |
| Last Update Date | 2021-11-11 |