| NPI | 1164937769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX U5558) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 39362) |
| Enumeration Date | 2017-12-05 |
| Last Update Date | 2025-10-25 |