| NPI | 1104987973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 20780) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: PR 2147) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2013-01-28 |