| NPI | 1225015068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MO 2009028839) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MI SD019274) |
| Enumeration Date | 2005-12-22 |
| Last Update Date | 2014-08-29 |