| NPI | 1396868774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 49568) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: CA 106145) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301086538) | |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2013-05-02 |