| NPI | 1407059009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN S49) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 0022997) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WI 6859-15) | |
| Enumeration Date | 2007-06-09 |
| Last Update Date | 2012-08-06 |