| NPI | 1639466733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: IA DDS-09277) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 056086) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-07-09 |
| Last Update Date | 2018-03-17 |