| NPI | 1306164066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX T1511) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 37153) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: IL 021.002766) | |
| 208600000X Surgery (Licence: IL 036.141884) | |
| Enumeration Date | 2010-05-05 |
| Last Update Date | 2021-08-25 |