| NPI | 1053302075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CO 10364) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: WY 1236) |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2014-01-29 |