| NPI | 1104991363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: OR MD15327) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: OR 6119) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: SC 17195) | |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2015-04-23 |