| NPI | 1104855634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: PA MD421768) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS025560L) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2015-09-03 |