| NPI | 1164634135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MO 2011001387) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 23369) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY P56783) | |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2023-04-11 |