| NPI | 1205240371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 31701) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62320) |
| Enumeration Date | 2014-06-17 |
| Last Update Date | 2019-03-09 |