| NPI | 1245252659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: PA DS024081L) |
| Additional Taxonomies | 1223P0106X Dentist Oral and Maxillofacial Pathology (Licence: PA DS-024081-L) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2015-06-22 |