| NPI | 1639514896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: UT 11640344-9924) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 64079) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-05-01 |
| Last Update Date | 2022-04-13 |