| NPI | 1861719254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NM DD3621) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3621) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-04-26 |
| Last Update Date | 2023-03-20 |