| NPI | 1558622712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MI 4301109597) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901020703) |
| Enumeration Date | 2012-06-05 |
| Last Update Date | 2018-06-08 |