| NPI | 1104338185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 37745) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0401417907) |
| Enumeration Date | 2017-10-30 |
| Last Update Date | 2023-12-04 |