| NPI | 1306122205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NY 304925) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY 060895) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: FL DN19525) | |
| Enumeration Date | 2011-10-25 |
| Last Update Date | 2025-02-08 |