| NPI | 1225565682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 33351) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: KS 62441) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: MO 2026024973) | |
| Enumeration Date | 2017-05-16 |
| Last Update Date | 2026-07-14 |