| NPI | 1225487622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CA 65087) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 65087) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 65087) | |
| Enumeration Date | 2016-06-07 |
| Last Update Date | 2018-12-18 |