| NPI | 1255337481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: GA DN012474) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901015818) |
| Enumeration Date | 2005-06-22 |
| Last Update Date | 2007-07-08 |