| NPI | 1962903112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE61485147) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NJ 22DI03148100) |
| 122300000X Dentist (Licence: IL 019.031837) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-02-22 |
| Last Update Date | 2026-05-08 |