| NPI | 1124381629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: OR MD191912) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 33845) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: MI 2901020742) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: TX R6146) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: MI 4301109828) | |
| Enumeration Date | 2012-06-19 |
| Last Update Date | 2019-06-29 |