| NPI | 1255591517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OK 4822) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: OK 4822) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: OK 4822) | |
| Enumeration Date | 2008-06-11 |
| Last Update Date | 2008-06-11 |