| NPI | 1619209939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: LA 303430) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: LA 6044) | |
| Enumeration Date | 2010-02-11 |
| Last Update Date | 2021-12-01 |