| NPI | 1275619124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 042847) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 37107) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: TX 37107) | |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2024-08-05 |