| NPI | 1003812298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: PR D2373) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 22096) |
| Enumeration Date | 2005-06-22 |
| Last Update Date | 2007-07-08 |