| NPI | 1043697543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: FL DRPM2328) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001125-15) |
| Enumeration Date | 2015-05-04 |
| Last Update Date | 2021-06-11 |