| NPI | 1396165965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 103556) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401414845) |
| 1223G0001X Dentist, General Practice (Licence: TX 36245) | |
| 1223G0001X Dentist, General Practice (Licence: KY 10707) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 36245) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 10707) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2021-11-12 |