| NPI | 1205006509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: VA 0101247300) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02234700) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0401412743) | |
| Enumeration Date | 2008-03-03 |
| Last Update Date | 2018-08-02 |