| NPI | 1497100341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NM DD5400) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA 17772396) |
| Enumeration Date | 2016-04-28 |
| Last Update Date | 2021-07-27 |