| NPI | 1780831487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 10474) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: AZ 8183) | |
| Enumeration Date | 2008-08-25 |
| Last Update Date | 2017-02-14 |