| NPI | 1124349212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2011008413) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KS 62200) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 390200000X) | |
| Enumeration Date | 2010-06-12 |
| Last Update Date | 2025-12-04 |