| NPI | 1053751594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 2019-02926) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 11689) |
| 208600000X Surgery (Licence: NC 2019-02926) | |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2022-04-13 |