| NPI | 1083718613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901012852) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: MI 2901012852) |
| Enumeration Date | 2006-09-12 |
| Last Update Date | 2019-07-23 |