| NPI | 1164545869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE60019072) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901018359) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301087381) | |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2021-04-19 |