| NPI | 1154717999 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207YS0123X Otolaryngology, Facial Plastic Surgery (Licence: FL ME149915) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN21733) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-08 |
| Last Update Date | 2022-02-08 |