| NPI | 1013358985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CO DEN.00203955) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 29310) |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2023-06-01 |