| NPI | 1285759720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MO 2017017086) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4281) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2019-05-09 |