| NPI | 1649690025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: OK 6594) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: DE G3-0000418) |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2018-06-28 |