| NPI | 1154795656 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CA 64035) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 64034) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 64034) | |
| Enumeration Date | 2015-11-20 |
| Last Update Date | 2020-06-25 |