| NPI | 1235511890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: SC 8651) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: SC 8651) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: GA DN016156) | |
| Enumeration Date | 2015-06-19 |
| Last Update Date | 2021-02-24 |