| NPI | 1194032284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX R0626) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25460) |
| Enumeration Date | 2010-09-10 |
| Last Update Date | 2016-12-01 |