| NPI | 1235663113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 10659) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: PA MD481288) |
| Enumeration Date | 2017-04-17 |
| Last Update Date | 2025-05-23 |