| NPI | 1184863813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MO 2008015944) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2008015944) |
| Enumeration Date | 2009-02-19 |
| Last Update Date | 2020-12-02 |