| NPI | 1013448885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 38316) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 9954) |
| Enumeration Date | 2017-03-23 |
| Last Update Date | 2023-07-07 |