| NPI | 1356504005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: UT 8583943-9924) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 204E00000X Oral & Maxillofacial Surgery (Licence: WY 1381) | |
| Enumeration Date | 2008-07-02 |
| Last Update Date | 2018-09-06 |