| NPI | 1982130779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 33185) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2023-10-04 |