| NPI | 1194150946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: SC 9549) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62674) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: WA 61302962) | |
| Enumeration Date | 2013-09-12 |
| Last Update Date | 2022-12-24 |