| NPI | 1134505399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: KS 61536) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6734) |
| Enumeration Date | 2015-08-10 |
| Last Update Date | 2019-11-12 |