| NPI | 1215101209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 28461) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: TX Q6702) |
| Enumeration Date | 2008-04-21 |
| Last Update Date | 2018-10-22 |