| NPI | 1154989556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: PA MD491255) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: PA DS042265) |
| Enumeration Date | 2019-05-31 |
| Last Update Date | 2025-07-15 |