| NPI | 1174564322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: IA 10410) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 042919) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2026-08-26 |