| NPI | 1164829438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MI 2901021463) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 2021-02207) |
| Enumeration Date | 2014-12-02 |
| Last Update Date | 2022-06-22 |