| NPI | 1063479988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: PA DS018965L) |
| Additional Taxonomies | 207L00000X Anesthesiology (Licence: PA DA018965A) |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2007-07-08 |