| NPI | 1306266143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 30251) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 30251) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-04-20 |
| Last Update Date | 2025-08-18 |