| NPI | 1255777330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D10814) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2013020368) |
| Enumeration Date | 2013-05-16 |
| Last Update Date | 2022-08-16 |