| NPI | 1225322019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 101077) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 34607) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: CA 157675) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: TX 34607) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-06-08 |
| Last Update Date | 2019-10-31 |