| NPI | 1114555448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 12613) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 018.002141) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: IL 019.032918) | |
| Enumeration Date | 2020-03-31 |
| Last Update Date | 2024-01-30 |