| NPI | 1003296831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NC 11566) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: SC 9450) |
| Enumeration Date | 2015-06-07 |
| Last Update Date | 2023-11-22 |