| NPI | 1538303144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA 60478567) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 282NC0060X General Acute Care Hospital, Critical Access (Licence: WA 60478567) | |
| Enumeration Date | 2009-04-27 |
| Last Update Date | 2014-10-30 |