| NPI | 1043385768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MI 2901019237) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019237) |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2016-02-22 |