| NPI | 1104837962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: KY 5285) |
| Additional Taxonomies | 208600000X Surgery (Licence: KY 5285) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2008-07-02 |