| NPI | 1124310685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: UT 9924) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 60916) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 30862) | |
| Enumeration Date | 2011-05-03 |
| Last Update Date | 2015-09-18 |