| NPI | 1104302264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: MO 2020029123) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 33972) |
| 122300000X Dentist (Licence: MI 2901022718) | |
| 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: TX 33972) | |
| Enumeration Date | 2018-07-12 |
| Last Update Date | 2020-09-04 |