| NPI | 1053490961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CA C139636) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 052760) |
| 122300000X Dentist (Licence: CA 64626) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: CT 049194) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: NY 257471) | |
| Enumeration Date | 2006-11-02 |
| Last Update Date | 2022-02-27 |