| NPI | 1265422893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 54820) |
| Additional Taxonomies | 208600000X Surgery (Licence: MA 20166) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2021-05-10 |