| NPI | 1275831208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CO 000203543) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: CA 101382) |
| 261QA1903X Clinic/Center, Ambulatory Surgical (Licence: CA a146736) | |
| Enumeration Date | 2011-02-28 |
| Last Update Date | 2018-05-05 |